Acute Mastoiditis in Children – A National Study in Sweden

One of the greatest threats to society today is the development of bacterial resistance to antibiotics. It is commonly accepted that this is mainly due to the use of antibiotics. Acute otitis media (AOM) is responsible for the highest number of antibiotic prescriptions to children although it is in most cases a self-limiting disease. Nevertheless, complications do occur in some case and the most common complication is acute mastoiditis (AM). Treatment guidelines advocating the restrictive use of antibiotics in uncomplicated AOM have been implemented hoping to slow down the development of resistance to antibiotics. This has led to concerns that an increase of complications will arise. Although AOM is extremely common in early childhood, only 20–60 cases of AM in children are encountered per year in Sweden. In the pre-antibiotic era AM was often lethal and the use of antibiotics has revolutionized the clinical course of severe AOM and AM, radically reducing the rate of complications and mortality. In addition to the new guidelines, in the year 2009, immunisation with pneumococcal conjugate vaccine (PCV) against the most invasive serotypes of Streptococcus pneumoniae, the most common bacteria causing AOM as well as AM, was introduced into the standard immunisation schedule in Sweden. The national study “Mastoiditis in Sweden”, which formed the basis for the research presented in this thesis, gives a good picture of Swedish paediatric patients suffering from AM. The different ways in which AM symptoms are expressed and their development in different age groups are well described in Paper 1. Different surgical methods for treating subperiosteal abscesses were evaluated in Paper 2. It was found that needle aspiration and/or incision to treat SA had no adverse effects when compared to mastoidectomy. Possible effects of the recently introduced immunisation against pneumococci were investigated in the third study (Paper 3). PCV did not offer a complete protection against the serotypes included in the vaccines, even in fully immunised children. Finally, the effects of the altered guidelines on AOM treatment were explored in an attempt to identify risk factors for AM (Paper 4). No overlooked possible risk factors for AM could be identified. Unfortunately, the retroauricular findings indicating an AM, were found to be overlooked by physicians at the primary assessment of some children, which caused a delayed treatment. Thus the AOM treatment guidelines appear to be sufficient, and the greatest challenge lies in detecting complications arising from AOM

Implementation of ecodesign methods into Nobia's design process

Examensarbetet har genomförts vid Högskolan i Skövde i samverkan med Nobia AB. Målet var att implementera ekodesignmetoder i Nobias befintliga designprocess och att genomföra en fallstudie på en kökslucka. Fallstudien genomfördes för att verifiera ekodesignprocessen och för att föreslå ett lämpligt material till en kökslucka. Under litteraturstudien undersöktes begrepp såsom hållbar utveckling, ekodesign och livscykel. Intervjuer genomfördes för att undersöka Nobias designprocess och för att identifiera aktiviteterna i varje fas i processen. Faserna var Idégenerering, Konceptutveckling, Produktutveckling och Industrialisering. Flera alternativa ekodesignmetoder studerades för att undersöka om de var lämpliga att implementera i Nobias befintliga designprocess, bland annat Statusanalys och olika Checklistor. De förväntade egenskaperna för ekodesignprocessen sammanställdes i en kravspecifikation. Ekodesignmetoderna som implementerades i Nobias befintliga designprocess resulterade i en ekodesignprocess, som bestod av Ekostrategihjul, Philips five fast, Jämförelsematris, Ekodesignportfolio, Miljöriskanalys och Scorecard. Fallstudien inleddes med skapandet av en kravspecifikation beträffande materialets förväntade egenskaper. De mest intressanta materialen var Medium Density Fibreboard, bambu och gran. Genom en analys av olika material ansågs gran vara det bästa materialet, eftersom det medförde minst utsläpp vid transport, tillgången är god samt är lokalt producerat. Det framkom att tillämpningen av ekodesign inom produktutveckling medför många fördelar, som till exempel en trivsam arbetsplats, motiverade medarbetare och en mer hållbar designprocess. En hållbar designprocess bidrar till att utveckla hållbara produkter, vilket bidrar till en bättre miljö.The bachelor project has been carried out at the University of Skövde in collaboration with Nobia AB. The purpose of the project was to implement eco-design methods into the company’s existing design process and to accomplish a case study of a cabinet door. The purpose of the case study was to verify the proposed eco-design process and suggest a material for a cabinet door. Sustainable development, eco-design and lifecycle were studied during the literature study. Interviews were carried out to study the design process at Nobia and to identify the different activities in every phase of the process. The phases were Idea Generation, Concept Development, Product Development and Industrialization. Several eco-design methods were studied to assess their potential to be implemented into Nobia’s existing design process, for example Status Analysis and various Checklists. The expected characteristics of the eco-design process were compiled into a requirement specification. The methods which were implemented into Nobia’s existing design process resulted in an Eco-design process which consisted of Ekostrategihjul, Philips five fast, Jämförelsematris, Eco-design portfolio, Environmental Failure Mode and Effect Analysis and Scorecard. The case study was initiated by compiling a requirement specification. The most promising materials were Medium Density Fibreboard, bamboo and fir. Through analysis of various materials fir was considered as the best material because of low levels of pollution during transportation, good access to the raw material and it is also locally manufactured. The results show that the use of eco-design within product development entails many advantages, such as, a pleasant place of work, motivated staff, and a more sustainable design process. A sustainable design process will contribute to the development of sustainable products, which entails a better environment

Infants under the age of six months with acute mastoiditis. A descriptive study of 15 years in Sweden.

To investigate the occurrence, clinical signs and outcome of acute mastoiditis in infants under the age of 6 months in Sweden between the years 1993-2007

Subperiosteal abscesses in acute mastoiditis in 115 Swedish children.

To study the outcome of different surgical methods of treating subperiosteal abscesses resulting from acute mastoiditis

Acute mastoiditis in children in Sweden 1993-2007-No increase after new guidelines.

OBJECTIVE: To study whether the incidence and characteristics of acute mastoiditis in children changed in Sweden following the introduction of new guidelines for diagnosis and treatment of acute otitis media advocating "watchful waiting" as an option in children 2-16 years of age with uncomplicated acute otitis media. METHODS: The records for all patients treated for mastoiditis during 1993-2007 at all Ear, Nose and Throat departments in Sweden were reviewed retrospectively according to defined criteria for acute mastoiditis. In this study the data from children aged 0-16 years were analyzed and compared 71/2 years before and 71/2 years after the introduction of the new guidelines in 2000. RESULTS: A total of 577 cases aged 0-16 years fulfilled the inclusion criteria during the whole study period. Cases involving cholesteatoma were excluded. The number of children affected by acute mastoiditis did not increase after the introduction of new guidelines. Acute mastoiditis was most common in children younger than two years of age. The proportion of acute mastoiditis increased after 2000 in the group aged 2-23 months although they were not affected concerning treatment by the new guidelines. No decrease was found in the frequency of prehospital antibiotic treatment among the children admitted with acute mastoiditis, and no increase was seen in the duration of ear symptoms before hospital admission, duration of hospital stay, or in the frequency of complications or mastoidectomies, after the introduction of the new guidelines in either group of children. CONCLUSIONS: The incidence of acute mastoiditis in children in Sweden did not increase following the introduction of new guidelines in 2000 for the diagnosis and treatment of acute otitis media. This is despite the fact that a significant decrease in antibiotic prescriptions for otitis media has been reported during the same time period. The characteristics of acute mastoiditis reflecting severity of illness did not change over time. Acute mastoiditis was most common and increased after 2000 only in children younger than two years of age in which antibiotics were still recommended in all cases of acute otitis media

Acute mastoiditis in children aged 0-16 years-A national study of 678 cases in Sweden comparing different age groups.

OBJECTIVE: To compare the characteristics of acute mastoiditis in children in different age groups in order to identify risk groups and risk factors for acute mastoiditis. METHODS: Records for all children aged 0-16 years treated for acute mastoiditis during 1993-2007 at 33 Ear, Nose and Throat departments in Sweden were reviewed retrospectively according to defined criteria for acute mastoiditis. RESULTS: A total of 678 cases fulfilled the inclusion criteria. Acute mastoiditis was most common in children younger than two years of age and this group was characterized by less prior history of other diseases and ear diseases, fewer visits to health care centers and less antibiotic treatment before admission, shorter duration of symptoms before admission, hospitalization for fewer days and lower frequency of complications and mastoidectomies. These children also showed a higher incidence of clinical findings, increased inflammatory markers such as fever and heightened counts of C-reactive protein and white blood cells compared with older children. They also tested positive for significantly more samples of Streptococcus pneumoniae while the older children more often exhibited growth of Streptococcus pyogenes or Pseudomonas aeruginosa or no microbial growth. CONCLUSIONS: The characteristics of pediatric acute mastoiditis differed significantly between age groups. Acute mastoiditis was most common in children younger than two years of age. They showed more rapid progress of symptoms and more distinct signs of acute mastoiditis. This is probably the reason why parents rapidly seek medical care for small children and hospital treatment thus starts earlier in the youngest children, which may in turn explain the excellent outcome. This study showed that younger children have neither more severe acute mastoiditis nor more complications than older ones. The differences between age groups suggest that there are distinctions in the pathophysiology behind the onset and course of acute mastoiditis in younger and older children

Niche- and gender-dependent immune reactions in relation to the microbiota profile in pediatric patients with otitis media with effusion

Otitis media with effusion (OME) is a common inflammatory disease, primarily affecting children. OME is defined as a chronic low-grade inflammation of the middle ear (ME), without any signs of infection and with effusion persisting in the ME for more than three months. The precise pathogenesis is, however, not fully understood. Here, we comprehensively characterized and compared the host immune responses (inflammatory cells and mediators) and the overall microbial community composition (microbiota) present in matched middle ear effusion samples (MEE), external ear canal lavages, and nasopharynx (NPH) samples from children with OME. Female patients had significantly increased percentages of T lymphocytes and higher levels of a wide array of inflammatory mediators in their MEEs compared to male patients, which was unrelated to microbiota composition. The relative abundances of identified microorganisms were strongly associated with their niche of origin. Furthermore, specific inflammatory mediators were highly correlated with certain bacterial species. Interestingly, some organisms displayed a niche-driven inflammation pattern, where presence of Haemophilus spp and Corynebacterium propinquum in MEEs was accompanied by pro-inflammatory mediators, whereas their presence in NPH was accompanied by anti-inflammatory mediators. For Turicella and Alloiococcus we found exactly the opposite results, i.e., an anti-inflammatory profile when present in MEEs, whereas their presence in the NPH was accompanied by a pro-inflammatory profile. Altogether, our results indicate that immune responses in children with OME are highly niche- and microbiota-driven, but gender-based differences were also observed, providing novel insight into potential pathogenic mechanisms behind OME

Molecular stratification of metastatic melanoma using gene expression profiling : Prediction of survival outcome and benefit from molecular targeted therapy

Melanoma is currently divided on a genetic level according to mutational status. However, this classification does not optimally predict prognosis. In prior studies, we have defined gene expression phenotypes (high-immune, pigmentation, proliferative and normal-like), which are predictive of survival outcome as well as informative of biology. Herein, we employed a population-based metastatic melanoma cohort and external cohorts to determine the prognostic and predictive significance of the gene expression phenotypes. We performed expression profiling on 214 cutaneous melanoma tumors and found an increased risk of developing distant metastases in the pigmentation (HR, 1.9; 95% CI, 1.05-3.28; P=0.03) and proliferative (HR, 2.8; 95% CI, 1.43-5.57; P=0.003) groups as compared to the high-immune response group. Further genetic characterization of melanomas using targeted deep-sequencing revealed similar mutational patterns across these phenotypes. We also used publicly available expression profiling data from melanoma patients treated with targeted or vaccine therapy in order to determine if our signatures predicted therapeutic response. In patients receiving targeted therapy, melanomas resistant to targeted therapy were enriched in the MITF-low proliferative subtype as compared to pre-treatment biopsies (P=0.02). In summary, the melanoma gene expression phenotypes are highly predictive of survival outcome and can further help to discriminate patients responding to targeted therapy